The Influence of Chronic Kidney Disease on the Structural and Mechanical Properties of Canine Bone.

BACKGROUND: Chronic kidney disease (CKD) is common in companion animals. Secondary hyperparathyroidism is an inevitable consequence of the disease and may have deleterious effect on the bone; however, the information regarding CKD-associated bone abnormalities in companion animals is scarce. HYPOTHESIS/OBJECTIVES: Dogs with CKD have decreased bone quality compared to dogs without CKD. ANIMALS: Nine dogs diagnosed with naturally occurring CKD for at least 6 months and 9 age-matched controls. METHODS: Dogs with CKD were enrolled and compared to 9 age-, weight-, and sex-matched control dogs with no evidence of CKD. Samples were assessed using light microscopy, mechanical testing, and microcomputed tomography. Variables evaluated included microstructural features such as number, size, and density of Haversian canals, resorption cavities and osteocytic lacunae, bone mineral density, porosity and Young's modulus. RESULTS: Median lacunae size was significantly smaller in the CKD group compared to the control group (P = 0.001). Resorption cavity density was higher in the CKD compared to the control group (10 [8-14] vs. 7 [4-9]/mm2 , respectively, P = 0.001). Overall porosity was significantly (2.3-fold) higher in the CKD compared to the control group. There was no difference in Young's moduli between groups. CONCLUSIONS AND CLINICAL IMPORTANCE: Naturally occurring CKD affects bone quality in dogs, but these changes are relatively mild and likely not to be manifested clinically. The duration of the disease in dogs evaluated here is short compared to cats and human patients, likely accounting for the more subtle changes in dogs compared to other species.

Maternal and genetic effects on broiler bone properties during incubation period.

In order to examine the differences in bone properties between fast-growing and slow-growing broiler embryos and to understand the effects of genotype and egg size on these differences, fast- and slow-growing hens and males were reciprocally crossed to create 4 egg groups: FST (laid by fast-growing hens, inseminated by fast-growing males), H-FST (fast-growing hens and slow-growing males), H-SLW (slow-growing hens and fast-growing males), and SLW (slow-growing hens and slow-growing males). Embryos (n = 8) from these 4 groups were sacrificed and weighed, and both tibiae were harvested on embryonic d (E) 17, 19, and 21. Left tibiae were tested for their whole-bone mechanical properties using a micromechanical device. Cortical bone structure and bone mineral density (BMD) were examined by micro-computed tomography of the left tibiae. Bone mineralization was evaluated by measuring BMD and ash content, while the rate and location of mineralization were evaluated by fluorochrome labeling. Osteoclastic activity and osteocyte density were evaluated by histological stains [TRAP (Tartrate resistant acid phosphatase) and H&E (Hematoxylin and Eosin), respectively]. Groups with larger eggs (FST and H-FST) had higher BW and tibia weight than groups with smaller eggs (SLW and H-SLW); however, they had a lower ratio of tibia weight to BW. Between groups with similar egg weight, stiffness, maximal load, and yield load of the bones were higher in the SLW than the H-SLW, while no differences were found between the FST and H-FST. Additionally, the tibiae of the SLW were stiffer and their osteocyte density higher than in the FST on E21 and their periosteal mineralization rate was higher between E19 and E21. No differences were found between the groups in cortical bone structure. This study demonstrates that faster growing hatchlings, especially those that hatch from relatively small eggs, have inferior bone mechanical properties in comparison to slower growing hatchlings, and suggests that fast-growing chicks hatching from small eggs are at a higher risk for developing bone pathologies. Accordingly, selection for increased egg size may lead to improved mechanical performance of the skeleton of fast-growing broilers.

Structure, composition, mechanics and growth of spines of the dorsal fin of blue tilapia Oreochromis aureus and common carp Cyprinus carpio.

The structural, compositional and mechanical properties of the spines of the dorsal fin in mature anosteocytic blue tilapia Oreochromis aureus and osteocytic common carp Cyprinus carpio are described, as well as their temporal growth pattern and regenerative capacities. The three-dimensional architecture of both spines, from macro to sub-micron levels, is shown to be axially oriented and therefore highly anisotropic and the spines of both species are able to regenerate after partial amputation.

In ovo feeding with minerals and vitamin D3 improves bone properties in hatchlings and mature broilers.

The objective of this study was to examine the effect of in ovo feeding (IOF) with inorganic minerals or organic minerals and vitamin D3 on bone properties and mineral consumption. Eggs were incubated and divided into 4 groups: IOF with organic minerals, phosphate, and vitamin D3 (IOF-OMD); IOF with inorganic minerals and phosphate (IOF-IM); sham; and non-treated controls (NTC). IOF was performed on embryonic day (E) 17; tibiae and yolk samples were taken on E19 and E21. Post-hatch, only chicks from the IOF-OMD, sham, and NTC were raised, and tibiae were taken on d 10 and 38. Yolk mineral content was examined by inductively coupled plasma spectroscopy. Tibiae were tested for their whole-bone mechanical properties, and mid-diaphysis bone sections were indented in a micro-indenter to determine bone material stiffness (Young's modulus). Micro-computed tomography (µCT) was used to examine cortical and trabecular bone structure. Ash content analysis was used to examine bone mineralization. A latency-to-lie (LTL) test was used to measure standing ability of the d 38 broilers. The results showed that embryos from both IOF-OMD and IOF-IM treatments had elevated Cu, Mn, and Zn amounts in the yolk on E19 and E21 and consumed more of these minerals (between E19 and E21) in comparison to the sham and NTC. On E21, these hatchlings had higher whole-bone stiffness in comparison to the NTC. On d 38, the IOF-OMD had higher ash content, elevated whole-bone stiffness, and elevated Young's modulus (in males) in comparison to the sham and NTC; however, no differences in standing ability were found. Very few structural differences were seen during the whole experiment. This study demonstrates that mineral supplementation by in ovo feeding is sufficient to induce higher mineral consumption from the yolk, regardless of its chemical form or the presence of vitamin D3. Additionally, IOF with organic minerals and vitamin D3 can increase bone ash content, as well as stiffness of the whole bone and bone material in the mature broiler, but does not lead to longer LTL.

The effect of hydration on mechanical anisotropy, topography and fibril organization of the osteonal lamellae.

The effect of hydration on the mechanical properties of osteonal bone, in directions parallel and perpendicular to the bone axis, was studied on three length scales: (i) the mineralized fibril level (~100 nm), (ii) the lamellar level (~6 µm); and (iii) the osteon level (up to ~30 µm).We used a number of techniques, namely atomic force microscopy (AFM), nanoindentation and microindentation. The mechanical properties (stiffness, modulus and/or hardness) have been studied under dry and wet conditions. On all three length scales the mechanical properties under dry conditions were found to be higher by 30-50% compared to wet conditions. Also the mechanical anisotropy, represented by the ratio between the properties in directions parallel and perpendicular to the osteon axis (anisotropy ratio, designated here by AnR), surprisingly decreased somewhat upon hydration. AFM imaging of osteonal lamellae revealed a disappearance of the distinctive lamellar structure under wet conditions. Altogether, these results suggest that a change in mineralized fibril orientation takes place upon hydration.

Unremodeled endochondral bone is a major architectural component of the cortical bone of the rat (Rattus norvegicus).

The laboratory rat is one of the most frequently-used animal models for studying bone biology and skeletal diseases. Here we show that a substantial portion of the cortical bone of mature rats is primary endochondral bone, consisting of a disorganized arrangement of mineralized collagen fibers. We characterize the structure and mechanical properties of the cortical bone of the rat. We show that the cortical bone consists of two architecturally distinct regions. One region, consisting of well-organized circumferential lamellae (CLB), is located in the endosteal and/or the periosteal regions while another, disorganized region, is located in the more central region of the cortex. Unexpectedly, we found that the disorganized region contains many islands of highly mineralized cartilage. Micro tomography showed different structural and compositional properties of the two primary structural elements; the CLB region has lower mineral density, lower porosity, larger but fewer blood vessels and fewer lacunae. However, no difference was found in the average lacunar volume. Additionally the mean indentation modulus of the CLB region was lower than that of the disorganized region. The islands of calcified cartilage were found to be extremely stiff, with an indentation modulus of 33.4 ± 3.5GPa. We conclude that though the cortical bone of rats is in part lamellar, its architecture is markedly different from that of the cortical bone of humans, a fact that must be borne in mind when using the rat as a model animal for studies of human bone biology and disease.

Prenatal nutritional manipulation by in ovo enrichment influences bone structure, composition, and mechanical properties.

The objective of this study was to examine the effect of embryonic nutritional enrichment on the development and properties of broiler leg bones (tibia and femur) from the prenatal period until maturity. To accomplish the objective, 300 eggs were divided into 2 groups: a noninjected group (control) and a group injected in ovo with a solution containing minerals, vitamins, and carbohydrates (enriched). Tibia and femur from both legs were harvested from chicks on embryonic days 19 (E19) and 21 (E21) and d 3, 7, 14, 28, and 54 posthatch (n = 8). The bones were mechanically tested (stiffness, maximal load, and work to fracture) and scanned in a micro-computed tomography (µCT) scanner to examine the structural properties of the cortical [cortical area, medullary area, cortical thickness, and maximal moment of inertia (Imax)] and trabecular (bone volume percent, trabecular thickness, and trabecular number) areas. To examine bone mineralization, bone mineral density (BMD) of the cortical area was obtained from the µCT scans, and bones were analyzed for the ash and mineral content. The results showed improved mechanical properties of the enriched group between E19 and d 3 and on d 14 (P < 0.05). Differences in cortical morphology were noted between E19 and d 14 as the enriched group had greater medullary area on E19 (femur), reduced medullary area on E21 (both bones), greater femoral cortical area on d 3, and greater Imax of both bones on d 14 (P < 0.05). The major differences in bone trabecular architecture were that the enriched group had greater bone volume percent and trabecular thickness in the tibia on d 7 and the femur on d 28 (P < 0.05). The pattern of mineralization between E19 and d 54 showed improved mineralization in the enriched group on E19 whereas on d 3 and 7, the control group showed a mineralization advantage, and on d 28 and 54, the enriched group showed again greater mineralization (P < 0.05). In summary, this study demonstrated that in ovo enrichment affects multiple bone properties pre- and postnatally and showed that avian embryos are a good model for studying the effect of embryonic nutrition on natal and postnatal development. Most importantly, the enrichment led to improved mechanical properties until d 14 (roughly third of the lifespan of the bird), a big advantage for the young broiler. Additionally, the improved mineralization and trabecular architecture on d 28 and 54 indicate a potential long-term effect of altering embryonic nutrition.

A temporary decrease in mineral density in perinatal mouse long bones.

Fetal and postnatal bone development in humans is traditionally viewed as a process characterized by progressively increasing mineral density. Yet, a temporary decrease in mineral density has been described in the long bones of infants in the immediate postnatal period. The mechanism that underlies this phenomenon, as well as its causes and consequences, remain unclear. Using daily µCT scans of murine femora and tibiae during perinatal development, we show that a temporary decrease in tissue mineral density (TMD) is evident in mice. By monitoring spatial and temporal structural changes during normal growth and in a mouse strain in which osteoclasts are non-functional (Src-null), we show that endosteal bone resorption is the main cause for the perinatal decrease in TMD. Mechanical testing revealed that this temporary decrease is correlated with reduced stiffness of the bones. We also show, by administration of a progestational agent to pregnant mice, that the decrease in TMD is not the result of parturition itself. This study provides a comprehensive view of perinatal long bone development in mice, and describes the process as well as the consequences of density fluctuation during this period.

Bone characteristics of late-term embryonic and hatchling broilers: bone development under extreme growth rate.

The development of broilers is an extreme example of rapid growth, increasing in weight from 40 g at hatch to 2,000 g 5 to 6 wk later. Such rapid growth requires a correspondingly fast development of the skeleton. Bone development is a genetically programmed process that is modified by epigenetic factors, mainly muscle-induced stresses and strains. In this study, we describe the temporal changes in bone morphology and material properties during the prehatch period [embryonic day (E) 14, E17, E19, E21] and posthatch d 3 and 7. The bones were examined for their weight, length, ash content, mechanical properties, and cortical structure. We show that the cross-sectional shape of the tibia and femur changes during the examination period from circular to elliptical. Additionally, the changes in bone properties are time-dependent and nonuniform: from E14 to E17 and from d 3 to 7, fast bone growth was noted, with major increases in both mechanical properties (stiffness, ultimate load, and energy to fracture) and geometric properties (cross-sectional area and thickness, medullary area, and moment of inertia). On the other hand, during the last days of incubation, most mechanical and geometric properties remain unchanged or even decrease. The reasons for this finding may relate to the hatching process but also to mineral shortage during the last days of incubation. This study leads to better understanding of bone development in ovo and posthatch in fast-growing broilers.

The canine baculum: the structure and mechanical properties of an unusual bone.

The baculum is an extraskeletal bone located in the penis of a few species in several orders of mammals such as carnivores, insectivores, rodents, bats and primates. This study aims to describe the structure, architecture and mechanical properties of the canine baculum. To this end canine bacula from castrated and uncastrated dogs were collected and examined by light microscopy, micro-computed tomography (microCT) scanning, histological staining, and mechanical testing. Their mineral density and mechanical properties were compared with those of a typical skeletal bone (the radius) in the same dog. Furthermore, a numerical model of a representative baculum was created and its mechanical performance analyzed using the finite element method, in order to try to elucidate its function. Examination of light microscopy images of transverse sections shows that the baculum consists of a typical sandwich structure, with two cortical plates separated, and joined, by loose cancellous bone. MicroCT scans reveal that the mineral density is lower in the baculum than in the radius, both in castrated as well as in uncastrated dogs, resulting in much lower stiffness. Castration was found to decrease the mineral density in both the baculum and the radius. The most likely function of the baculum of the dog is to stiffen the penis to assist intromission, and its much lower mineral density compared to that of the radius may be a mechanism designed to decrease the stiffness somewhat, and thus reduce the risk of fracture during copulation.

Segmental inertial properties in dogs determined by magnetic resonance imaging.

Data regarding the segmental inertial properties of the dog are currently unavailable, although such parameters are needed for dynamic analyses of canine motion. The purpose of this study was to measure the segmental inertial properties in three medium sized dogs of average build using magnetic resonance imaging. The parameters included the mass, location of centre of mass and moments of inertia for each body segment. The normalised results will serve as a preliminary foundation for various biomechanical studies in dogs, although further study is required to characterise them for specific dog breeds and to determine how they may be affected by age and gender.

Placental protein 13 as an early marker for pre-eclampsia: a prospective longitudinal study.

OBJECTIVE: To assess the value of placental protein 13 (PP13) as an early marker of pre-eclampsia. DESIGN: Sequential blood samples were obtained from women with singleton viable pregnancies at 6-10, 16-20 and 24-28 weeks of gestation. Samples were tested for PP13 using a solid-phase sandwich enzyme-linked immunosorbent assay. Levels were expressed as multiples of the medians (MoM) of the unaffected population. The slope or rate of change in PP13 concentration per week of gestation was also calculated. SETTING: Thirty-five prenatal care community clinics. SAMPLE: In total, 1,366 women were recruited, and subsequently, 20 were diagnosed with pre-eclampsia, 41 with gestational hypertension and 1,178 were unaffected. MAIN OUTCOME MEASURES: Sensitivity and specificity of screening with PP13 at each gestational period and of PP13 level combined with the slope of PP13 between two testing periods. RESULTS: At 6-10 gestational weeks, PP13 levels were significantly lower among the pre-eclampsia group with a median 0.28 MoM (95% CI 0.15-0.39, P < 0.004). Using a cutoff of 0.40 MoM, the sensitivity was 80%, false-positive rate (FPR) was 20% and odds ratio was 16.0 (95% CI 5.3-48.4). Combining MoM of 6-10 weeks and slope between 6-10 and 16-20 weeks, the sensitivity was 78%, the FPR was 6% and odds ratio was 55.5 (95% CI 18.2-169.2). The gestational hypertension group was not different from the normal group. CONCLUSIONS: PP13 in the first trimester alone or in combination with the slope between the first and the second trimesters may be a promising marker for assessing the risk of pre-eclampsia.

Successful management of bilateral patellar tendon rupture in a dog.

A seven-year-old, 41 kg, intact, cross breed dog, was presented with a history of bilateral hind limb lameness after falling from a height of 1 m. Clinical and radiographic findings were consistent with bilateral patellar tendon rupture. Surgical repair was performed bilaterally. The tendons were sutured primarily, and an internal splint of nylon leader was added. Good apposition of the severed tendon ends had been achieved intraoperatively; however, post operative radiographs showed supra-trochlear displacement of both patellae. The casts used to immobilize the stifle joints slipped distally and three days post operatively the tendon repair had broken down, bilaterally. Revision surgery was undertaken and the tendons were re-sutured. Nylon leader was placed through holes that had been drilled in the patellae and tibiae. The stifle joints were immobilized with type I external skeletal fixators (ESFs). Both freeform polymethylmethacrylate (PMMA) connecting bars were found to be broken at the level of the stifle joints two days later, without any disruption of the primary tendon repair. Each connecting bar was replaced with two connecting bars of PMMA reinforced with 3 mm steel wire. The dog was fully weight-bearing with a reduced range of motion in flexion immediately after removal of the ESFs at six weeks and was still sound 18 months post-operatively. Primary tendon repair in combination with adequate immobilization allowed for an excellent outcome in a complicated bilateral pathology.

Bacterial infective arthritis of the coxofemoral joint in dogs with hip dysplasia.

The objective of this study was to describe seven cases of unilateral bacterial infective coxarthritis from a total of 19 cases of bacterial infective arthritis (BIA), presenting over a two year period. We recorded the history, clinical signs, diagnostic process, treatment and clinical outcome in these cases. The data were obtained from medical records, review of the radiographs, and telephone follow-up with the owners. All of the dogs in this study had severe chronic osteoarthritis secondary to hip dysplasia, which caused periodic hind limb lameness. They were all admitted with severe acute hind-limb lameness. Pelvic radiographs were performed under general anaesthesia shortly after presentation, followed immediately by arthrocentesis of the affected joint. The synovial fluid was evaluated microscopically by direct smear and a sample was sent for culture and sensitivity. An attempt was not made to drain or lavage the affected joint during the course of treatment. The initial choice of antibiotics was empiric and subsequently modified, as required, based on the sensitivity results. Four of the dogs showed a rapid return to weight-bearing after the initiation of antibiotic treatment, and all of the patients returned to their pre-BIA level of function. Neither recurrent infections nor any adverse sequela requiring further intervention were reported by the owners on telephone follow-up.

Anisotropic Poisson's ratio and compression modulus of cortical bone determined by speckle interferometry.

Young's modulus and Poisson's ratios of 6mm-sized cubes of equine cortical bone were measured in compression using a micro-mechanical loading device. Surface displacements were determined by electronic speckle pattern-correlation interferometry. This method allows for non-destructive testing of very small samples in water. Analyses of standard materials showed that the method is accurate and precise for determining both Young's modulus and Poisson's ratio. Material properties were determined concurrently in three orthogonal anatomic directions (axial, radial and transverse). Young's modulus values were found to be anisotropic and consistent with values of equine cortical bone reported in the literature. Poisson's ratios were also found to be anisotropic, but lower than those previously reported. Poisson's ratios for the radial-transverse and transverse-radial directions were 0.15+/-0.02, for the axial-transverse and axial-radial directions 0.19+/-0.04, and for the transverse-axial and radial-axial direction 0.09+/-0.02 (mean+/-SD). Cubes located only millimetres apart had significantly different elastic properties, showing that significant spatial variation occurs in equine cortical bone.

A method for patient-specific evaluation of vertebral cancellous bone strength: in vitro validation.

BACKGROUND: In the context of osteoporosis, important determinants of the fracture risk are the apparent strength and stiffness of cancellous bone, as well as its brittleness and energy absorption capacity. Standard medical imaging, however, cannot measure these mechanical properties directly. Consequently, an estimation of the risk for fracture is made by correlating relative density or mineral density at a skeletal site with statistics of fracture occurrence, which provides limited and partial indications on fracture risks. A better method for evaluating the patient-specific mechanical properties of cancellous bone is therefore required. METHODS: In order to asses the mechanical properties of vertebral cancellous bone, we developed a finite element parametric model of lattice trabecular architecture that, in the future, will be suitable for use with bone imaging modalities. The model inputs are apparent morphological parameters (trabecular thickness and trabecular separation) and the bone mineral density. We conducted uniaxial compression tests on 36 canine vertebral cancellous bone specimens (C7 and L1) to validate model predictions of strength and stiffness in vitro. FINDINGS: Predictions of strength and stiffness matched the experimental results within relative absolute errors of 17.7% and 12.8%, respectively (average of differences between model-predicted and measured values, divided by the average of measured values). We also employed the model for evaluation of strength and stiffness of human L1 and L5 vertebrae and found mean strength of 1.67 MPa (confidence interval 0.42 MPa) and mean elastic modulus of 190 MPa (confidence interval 50 MPa), which are well within the range of previously reported apparent strength and stiffness properties. INTERPRETATION: The present model can be used to improve medical imaging-based evaluation of the spine in osteoporotic individuals by providing more specific information on the individual bone's susceptibility to fracture once clinical bone scans will be able to provide more reliable measures of trabecular thickness and separation.

Femoral compartment syndrome due to haemangiosarcoma in the semimembranosus muscle in a dog.

A five-year-old, entire male German shepherd dog was presented to the Veterinary Teaching Hospital-Koret School of Veterinary Medicine because of an acute, painful swelling of the right thigh and severe lameness of two-weeks duration. On physical examination, a firm and painful mass was detected in the hamstring region. Radiography and ultrasonography revealed a soft tissue mass, with a 250 cc fluid accumulation craniomedial to it. Intracompartmental pressure measurement with a Wick catheter demonstrated significantly elevated pressure within the right caudal femoral compartment (25 to 28 mmHg compared with 5 to 7 mmHg in the unaffected leg). Surgical exploration of the area was undertaken, fasciotomy and mass excision were performed, and resolution of the clinical signs was achieved. The mass was identified by histopathology results as haemangiosarcoma. Two and a half months after surgery, which was followed by adjunct chemotherapy (doxorubicin), the dog was readmitted with a subcutaneous mass in the same area, although he was not lame at this time. Radiographs of the thoracic cavity demonstrated widely disseminated metastases in the lungs. At that point, the owner elected to have the dog euthanased.

Arthrodesis of the tarsometatarsal joint, using type II ESF with acrylic connecting bars in four dogs.

Hyperextension injury of the tarsometatarsal joint (TMTJ) is a debilitating injury and arthrodesis of this joint is often the only procedure that can result in full return to function. Most surgical procedures described for arthrodesis of the tarsometatarsal joint necessitate the use of external, splint or cast, to protect the implants used from fatigue failure. This report describes the successful use of type II external fixator that spans the tarsometatarsal joint in four dogs with hyperextension injury of the tarsometatarsal joint. This technique enables the patient to bear weight on the limb immediately after surgery until bony fusion is achieved, without the need for an additional protecting splint.

How to select the elastic modulus for cancellous bone in patient-specific continuum models of the spine.

Patient-specific finite element (FE) modelling is a promising technology that is expected to support clinical assessment of the spine in the near future. To allow rapid, robust and economic patient-specific modelling of the whole spine or of large spine segments, it is practicable to consider vertebral cancellous bone in the spine as a continuum material, but the elastic modulus of that continuum material must reflect the quality of the individual vertebral bone. A numerical parametric model of lattice trabecular architecture has been developed for determining the apparent elastic modulus of cancellous bone Ecb in vertebrae. The model inputs were apparent morphological parameters (trabecular thickness TbTh and trabecular separation TbSp) and the bone mineral density (BMD), which can all be measured in vivo, using the spatial resolution of current clinical quantitative computed tomography (QCT) commercial whole-body scanners. The model predicted that Ecb values between 30 and 110 MPa represent normal morphology and BMD of human spinal cancellous bone. The present Ecb to TbTh, TbSp and BMD relationships pave the way for automatic generation of patient-specific continuum FE spine models that consider the individual's osteoporotic or other degenerative condition of cancellous bone.

Chondrosarcoma of the proximal humerus in a cat.

Chondrosarcoma of the proximal humerus was diagnosed in a four-year-old, castrated male, domestic shorthair cat that was presented with a slowly growing solid mass in the region of the proximal humerus. Forequarter amputation was advised, but declined by the owners. Following surgical debulking clinical signs resolved, but two months after surgery the cat was readmitted because the mass had recurred in the same region. The forequarter was amputated. Histopathological evaluation of the tumour confirmed the diagnosis of chondrosarcoma. Follow-up examinations performed over a period of 15 months from initial presentation revealed that the cat was doing well and had no signs of metastatic disease. To the authors' knowledge, this is the first reported case of chondrosarcoma of the proximal humerus in a cat to be diagnosed and surgically treated. This case demonstrates that animals with such tumours may recover well after complete excision.